Disposable Doctors

Posted: January 18, 2007 by Doc in Endings, ER Docs, Medical, Medical career, Medicine

disposable-doctors.gifDisposable People
When I started practice a little more than a decade ago, I got on staff at our suburban community hospital. With my shiny new diploma fresh out of training, I was probably more than a little condescending, having been taught at the big city academic medical center (BCAMC) where I trained, that REAL cutting edge medicine could only be practiced at BCAMCs.

Fortunately, I was knocked off my ivory tower , brought down to earth, and saved on what would turn out to be many, many occasions, by my favorite ER docs. These guys had battle experience, having worked in big city hospital ERs, they knew the patients, they had smarts, and heaps of common sense. Aside from taking care of a never-ending stream of patients, they also had to constantly beg for admission beds, cajole cranky consultants to come in, and sweet-talk the lab or radiology to speed up that blood test or CT scan. When I got that 2AM call from a wheezy asthmatic, all I had to do was send them to the ER and I could rest easy that my patient would be well cared for until I got there. We were a team, and I never even thought what it would be like without them to rely upon.

So, I was stunned when I heard that these wonderful doctors, who had served our community well for more than 10 years were being fired! Why? you may ask, and I asked the same question. The reason given was that they had not done a residency in Emergency Medicine and did not have ABEM certification! Now, please note that the ER docs in question had done residencies in Internal Medicine and Surgery and had board certifications in these specialties and/or were certified by the ABPS, and more importantly, WERE EXCELLENT ER PHYSICIANS AND HAD DONE AN OUTSTANDING JOB FOR MORE THAN 10 YEARS! Why would the hospital be one day happy with their services, then next day suddenly dispose of them like used Kleenex? Well, apparently the hospital CEO decided (without consulting the medical staff) that he would like to “improve” the ER by contracting with an outside company that would bring in their own doctors, none of whom we knew or ever met, but were ER residency trained and ABEM certified, and they did not hire non-ER trained ER physicians, thus our old ER docs were OUT. It is heart breaking and shameful that after devoting a significant portion of their lives and careers to this hospital and community, our ER docs were dismissed, (as if talented experienced physicians are so easily replaceable), through no fault of their own.

Apparently, this episode is not so uncommon nowadays. Nassau University Hospital planned to fire all of its ER doctors in 2005 and only backed down under pressure from the union. ER doctors in New Mexico and New York have also gotten the same shoddy treatment. I don’t understand this mad rush to replace good ER doctors when there is a supposed shortage of ER physicians and a full 38% of ER physicians in this country are NOT ER residency trained and ABEM certified, approximately 13,000 physicians.
What I also find distressing is that no one is speaking up for my friends. Not the AMA, and ACEP, which is supposed to advocate for ALL ER doctors (not just the ER trained, ABEM certified) has been far from helpful, in spite of their policy which states:

“A qualified emergency physician is defined as one who possesses the training and experience in
emergency medicine sufficient to evaluate and initially manage and treat all patients who seek emergency care. ACEP believes that the ED medical director should be responsible for assessing and making recommendations to the hospital’s credentialing body related to the qualifications of emergency physicians with respect to the clinical privileges granted to them. Such qualifications may include

    -professional credentials such as board certification;
    -objective measurement of care provided;
    -experience
    -prior training;
    -and evidence of continuing medical education.

Although board certification in emergency medicine is an excellent benchmark that should be considered when delineating clinical privileges,
no single criterion should provide the sole basis for decisions regarding an individual’s emergency medicine practice.
(Approved 1985; Revised 1991; Revised 1995; Reaffirmed 1999; Revised 2004)

Some organizations, such as the EMRA and the AAEM even actively campaign against their non-ER residency trained colleagues. Is this what we’ve come to? No wonder the malpractice lawyers and insurance companies have no problem picking us off. Instead of getting our act together and supporting one another, we are too busy stabbing each other in the back.

To the hospital staff’s credit, petitions were circulated, special meetings were held, and outraged letters to the administration and the press were written, there was much wailing and moaning, but to no avail. My friends are gone, and as one of the other doctors said, “The ER is a strange and cold place” without them. ER care since they left is more fragmented and confused, because the new guys are still on a learning curve and they don’t know the patients or the other docs.

All this has left those of us remaining disgusted and demoralized, but we will recover, and life will go on. Excuse me while I go throw up now.

Links:
“Qualifications” on Scalpel or Sword
“Rant” on Gruntdoc
Disposable Doctors 2: ER Docs Fight Back in NY
News from AAPS vs. NY-DOH

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Comments
  1. scalpel says:

    Texas is an “at-will employment” state, meaning that anyone can be terminated for any reason at any time. Nobody in my group even has a contract. I could easily envision getting squeezed out of a job for the same reason as the docs at your facility.

    What bothers me more is the fact that many positions are automatically closed to me without consideration of my qualifications or experience. Any application I might submit to certain elite groups would be immediately and unceremoniously dumped in the circular file because of my lack of ABEM certification. I would never even get an interview.

    And yet everyone admits that some of the best ER docs they know are not ABEM certified. Go figure.

    Thanks for this post. I love your blog.

  2. trenchy says:

    This issue at your hospital really has many angles. Certainly it highlights the problems that occur when a non-boarded group, or individuals are pushed out of a job because of thier non-boarded status. It will be an ongoing problem as there are still not enough EM residents to fill the needs of the Nations ER’s. The powers that be decided to close board certification to non-residency trained physicians and I suppose that they assumed it would allow folks to either go back and finish a residency or grandfather with only a few individuals caught in the middle.
    The reality is that many non-residency trained EP’s basically live in limbo with a fear of loosing thier position at any time.
    More importantly though, my guess is that your hospital administator used the “non-boarded” excuse to find a group that was a little cheaper. It happens in Emergency Medicine every day. Groups of 20-30 physicians and more have been sacked with no warning so a “mega-group” could come in to manage the ER… gleaming with promises of higher effeciency, better billing and lower cost. These promises enevitably fall flat within a year or so but by then the previous MD’s have moved on and the hospital and staff are left much worse off than before.
    It is a story that repeats itself over and over and the non-boarded ER physicians and their families usually pay the heaviest price.

  3. docwhisperer says:

    Thanks for your comments. But is there no remedy to this situation? Are the excellent ER docs (though non ABEM certified) like Scalpel and my friends just supposed to sit and wait helplessly as the powers that be decide their fates, when we already know the outcome isn’t going to be good? I hear even the ABEM certified, non-residency trained ER docs (those who were “grandfathered”) are also being removed from their ER positions. What is all this supposed to accomplish and who is really benefiting?

  4. It’s also happening here across the Atlantic. Good doctors are being kicked out onto the streets for stupid reasons that sound like they were dreamed up by a half-starved retard. It’s falling apart wherever you go.

    I’m sorry about your friends. It’s cos of doctors like them that the system has survived as long as it has, and now it falls to docs like you, I suppose.

    So students like me don’t go insane when we qualify.

  5. shadowfax says:

    I suspect that it was not the ER docs’ lack of ABEM certification that got them dumped. It may have played a part. But more likely they fell victim to a predatory contract management group, and the ABEM issue was used as a convenient pretext for a change in staffing. I wonder whether the old group of docs received any sort of subsidies or compensation from the hospital, and if the contract group — EMCare or EMP or EPMG or TeamHealth or one of those players — low-balled the hospital, making the CEO think he was getting some sort of cost savings.

    I would bet good money that there’s more to it than the board cert issue. One of the things about EM is that your contract is always in jeopardy and you have to pay attention to its care and feeding or one of those big groups will be too happy to replace you. If you look deep enough, I am sure there was some issue, political, financial, personal, quality, or performance which cost those docs their jobs. Not that I expect the CEO to admit it.

  6. tom says:

    My initial response to the post “Disposable Doctors” is that the CEO knew what he/she wanted to pay, but not what he/she wanted to (or needed to) buy. I am from California, where, in the late 1980’s, doctors and hospitals became commodities to be traded, hoarded (is whoreded a word) and otherwise exploited in pursuit of the promise of more patients/money. Coincident with that the “soft value” of relationships ended. The market became what was easily measured, bed days per 000, ROI, EBIDA, market share. Failure to contribute positively to all of those was deemed to be “failure” and a harbinger of chnge to come. What is the value of an ED that functions well? An ED where because of relationships an Orthopedic Surgeon will come in to see a patient or an ED where Registered Nurses choose to work? My guess is the CEO referenced in this post will soon find out!

  7. tom says:

    I felt a need to add a couple of more comments to my post above. I have noted the following regarding “Boards”
    Many competent physicians are Board Certified in their specialty.
    Many incompetent physicians are Board Certified in their specialties-one only need read their licensing board newsletter to confirm this.
    Many competent physicians are not Boarded in their specialty
    Many incompetent physicians are not Boarded in their specialty.

    So what does being Board Certified guarantee? Success on a test, no more, no less. The true test of competence is in the clinical arena not the testing arena! “You can’t sue me, I am Board Certified and that proves I know what I am doing!”

  8. trenchy says:

    excellent points Tom, although your logic is probably above hospital COO’s and any random 12 peers we might face in court.

  9. docwhisperer says:

    If I understand your meaning, Trenchy, you’re saying that the COO and a jury automatically assume that board certification is proof of greater competence. On what basis are these assumptions made? Since we work in an evidence based profession, have there been studies documenting that ABEM boarded physicians perform better than the ER docs who are non-ABEM certified but have been working in the ER for decades?

  10. tom says:

    Trenchy; my observations reflect a “30 year tour” as a Hospital Administrator. There still exists a role for the use of common sense in managing a hospital. I would like to know what the Nurses think about the non-ABEM certified docs=who would they choose in an emergency?

  11. trenchdoc says:

    No it is not a proof of greater competence to non-medical types but I believe they feel it is some proof of any competence.

  12. Chris says:

    The only option available to the dedicated EM docs (who may have 20 yrs of experience) that were closed out of ABEM grandfathering in 1987 is certification through ABPS. This process is more rigorous than ABEM’s now-defunct grandfather route. Yet ACEP, who is supposed to represent all ED docs, refuses to recognize it.

    As the older (often grandfathered) ED docs begin to retire, the need for well trained physicians to staff our EDs wil not lessen. There aren’t enough residents graduating to do this. If ACEP truly cared about assuring quality care in every ED across the country, they would recognize, and encourage ABPS. Instead, they’re saying people like you colleagues are second class citizens, while realizing that they’re essential.

    I’ve heard many stories of recent EM graduates who simply can’t function in a community hospital setting where they may not have 24 hr anesthesia, surgical subspecialists, medical consultants, trauma teams, CT, MRI, etc. And these folks are supposed to be the most knowledgeable…

  13. docwhisperer says:

    Absolutely, Chris! And now ACEP is trying to push a bill that won’t even let the “grandfathered” ABEM certified docs who didn’t do an EM residency (and everyone else) advertise that they are certified in Emergency Medicine! (see Disposable Docs 2: Newsflash)
    To top it off, my “disposed” colleagues just found out that their former employer who was supposed to cover their “tail insurance” and COBRA (for all those years they served in our ER) has not been making payments and they are now left to pick up a very expensive tab. Like my friends say, “This just keeps getting better”. I say they should seek legal representation.

  14. Alyce Garrity, MD says:

    Alaska is also an “at-will” state — but if you’ve got an MD or DO behind your name (or PA-C or NP), and you’re willing to work by yourself in the bush when it’s 30 below and even the Coast Guard can’t make in in for a Medevac due to the weather, they’ll be glad to take you. I wonder how many of our Residency trained/BC colleagues could handle this situation. Right now I’m sitting on a gal in labor with a transverse lie — and no ultrasound to help with a version. and this isn’t even a bad night, because my only other patient is sleeping off his 530 ETOH level — he’s only needed Haldol once so far. And it’s a long time until daylight, when the Coast Guard is going to try again. I challenge any of them to come up here for a month — hell, they probably wouldn’t last a week!

  15. docwhisperer says:

    This was the same situation with my ER friends (though not quite so isolated) when they started 15 years ago, back when the hospital did not have all the anesthesia, trauma, and surgery support staff it now has. Is it fair that after keeping the hospital and community afloat for so many years, once the hospital administration changed and the ER is now more attractive to EM trained docs (due to their efforts), my friends should suddenly be considered “sub-standard” and out of a job?

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  19. joe says:

    The ABEM closed the practice tract and even if you wanted to spend three years to do and EM residency, you will never get accepted. There is a shortage of residency positions and EM is a hot specialty so the funding issue will prevent you from being able to do a second residency. So you have just been thrown away, there are no second chances in medicine any more now that doctors have lost control of medicine and most hospitals to the MBAs and the Lawyers.

  20. Edward says:

    Residency trained in EM. ABPS/BCEM certified and still have trouble. So it must be “the exam and not the training”. Now what?

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